Common Pain Relievers Do Not Appear to Interfere With Mood Stabilizers

Many patients with unipolar or bipolar depression require analgesics to reduce pain associated with somatic comorbidities.

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While it is generally accepted that pain relievers can help these patients, several studies have suggested that nonsteroidal anti-inflammatory drugs (NSAIDs) may interfere with selective serotonin reuptake inhibitors (SSRIs). As a result, clinicians have become more cautious about prescribing NSAIDs to people with depression and bipolar disorder, Roger McIntyre, M.D., the head of the Mood Disorders Psychopharmacology Unit at Toronto’s University Health Network, told Psychiatric News.

A study in Depression and Anxiety suggests that concomitant use of NSAIDs and/or acetaminophen does not negatively impact the outcomes of bipolar patients receiving mood- stabilizing treatment.

For the large, multi-site pragmatic clinical trial known as the Clinical and Health Outcomes Initiatives in Comparative Effectiveness (CHOICE) for Bipolar Disorder Bipolar, 482 patients with bipolar disorder were randomly assigned to receive lithium (up to 900 mg daily) or quetiapine (up to 600 mg daily for acute depression or 800 mg daily for acute mania) for six months. To make the trial as reflective of real-world settings as possible, lead study author Ole Kohler-Forsberg, M.D., a clinical investigator at Aarhus University Hospital in Risskov, Denmark, told Psychiatric Newsthat the study did not exclude patients from taking other medications in addition to their assigned mood stabilizer throughout the trial.

Because the researchers sought to compare treatment outcomes in patients taking high doses of NSAIDS or acetaminophen with patients who were not on such high doses, patients taking ibuprofen as a temporary analgesic or low-dose aspirin for preventive cardiovascular health were not included in the analysis.

Psychiatric symptoms were assessed at the beginning of the study and then multiple times over the course of trial using both the Clinical Global Impression scale for bipolar disorder and the Bipolar Inventory of Symptoms Scale.

Patients taking NSAIDs and acetaminophen did not differ from nonusers with respect to treatment outcome with lithium or quetiapine at any time point during the six months of treatment. This association was true both when considering all pain reliever users together (177 participants) or NSAID/acetaminophen subgroups.

“The message from these findings is that co-medication with an anti-inflammatory does not interfere with a mood stabilizer,” Kohler-Forsberg said. He acknowledged that adding a second drug to a treatment may lead to more side effects, such as gastrointestinal bleeding or cardiovascular problems in the case of NSAIDs. “But if a patient has an indication that would benefit from an anti-inflammatory, then there is no inherent detrimental effect to prescribing one.”

McIntyre, who was not involved with the trial, said that he believes these findings are especially important given how commonly these drugs are already prescribed for bipolar patients. “In this study, 37 percent of the subjects were taking them regularly,” he said. “And until now there had been no direct studies to see if there was any interference.”

This study was supported by a grant from the Agency for Healthcare Research and Quality. ■